Triventricular Hydrocephalus Research Articles

One-year evaluation of the treatment of hydrocephalus associated with Galen\u2019s vein aneurysm: about 3 cases in a country with limited health resources

BackgroundAneurysm of vein of Galen is a rare congenital arteriovenous malformation. Clinical manifestations depend on the age of discovery. Endovascular embolization is currently the treatment of choice. This technique is not always available in developing countries. We report 3 cases treated symptomatically by endoscopic third ventriculostomy and ventriculoperitoneal shunt.Cases presentationThree patients, 7 months, 15 years, and 26 years old, received in a table of acute intracranial hypertension, associated for the first one with convulsions and for the second one with moderate heart failure. Bain CT scan revealed triventricular hydrocephalus secondary to sacciform dilatation of the Galen’s vein in all three patients, requiring symptomatic treatment by endoscopic third ventriculostomy for the first patient and ventriculoperitoneal shunt for the other two in the absence of an adequate clinical platform for endovascular embolization. The evolution was favorable at 1 year’s follow-up.ConclusionGalen’s vein aneurysm is a rare vascular malformation. It mainly affects newborns and small children but can be discovered in adulthood. Endovascular embolization is its treatment of choice. This technique is not always available in some countries, which makes it necessary to resort to symptomatic treatment by ventricular shunt.

Management of Complications Related to Hydatid Cysts: Case Report

This paper presents the case of a 13-year-old female patient, operated in 2015 for left temporoparietal hydatid cyst and reoperated in 2016 for recurrence of the cerebral hydatid cyst. At admission, his GCS scores were E3V4M5. Neurological examination revealed a hemilatéral motor deficit estimated at 3/5 on right side without sensitive trouble. The CT scan showed a large left temporal cystic formation with an infected appearance associated with 4 cystic formations with calcified walls exerting a mass effect on the adjacent parechyma and the homolateral lateral ventricle responsible for a triventricular hydrocephalus. No primary focus was found in the lungs, liver, or other organs. In this article, we will discuss the management of complications related to hydatid cysts. Cerebral hydatid cyst is a rare condition, affecting mainly children. The diagnosis of cerebral hydatid cyst must be evoked in endemic countries in front of a symptomatology of intra-cranial hypertension.

The role of mesencephalic aqueduct obstruction in hydrocephalus development: a case report

We report on three patients with mesencephalic aqueduct obstruction, which completely blocked the cerebrospinal fluid communication between the third and fourth cerebral ventricle, demonstrated by standard and high-resolution magnetic resonance sequences. Only one patient developed radiological and clinical presentation of hydrocephalus, without radiological signs of increased intraventricular pressure. The remaining two patients did not show clinical signs of hydrocephalus and had a normal radiological presentation of the ventricular system. These findings contradict the classical concept of cerebrospinal fluid physiology. This concept assumes a unidirectional circulation of cerebrospinal fluid through the mesencephalic aqueduct from the secretion site, predominantly in the choroid plexuses, to the resorption site, predominantly in the dural venous sinuses. Therefore, the obstruction of the mesencephalic aqueduct would inevitably lead to triventricular hypertensive hydrocephalus in all patients. The current observations, however, accord with the new concept of cerebrospinal fluid physiology, which postulates that cerebrospinal fluid does not circulate unidirectionally because it is both formed and resorbed along the entire capillary network within the central nervous system.

OCCIPITAL MENINGOCELEABOUT A CASE

Spinal dysraphisms represent a large set of congenital anomalies reflecting an embryological abnormality in the closing of the neural tube. Their incidence would be 1 to 2 per 1000 births. We report the case of a patient Admitted for decrease in active foetal movements. On examination, we find a presence of a tri-ventricular hydrocephalus associated with a rounded mass integral with the cephalic pole, of liquid and anechoic tone of 53 mm, evoking a meningocele. Obstetric ultrasound is the only imaging examination performed in systematic screening. It would however be interesting to be able to diagnose DSF and differentiate it from DSO, because the therapeutic possibilities and the prognosis are different.

Hydrocephalus in children – A rare case of pineal cavernoma and literature review

Background: Cavernous malformations prevalence ranges from 0.4 to 0.6% and accounts for 5–15% of all central nervous system vascular malformations. Pineal cavernomas constitute <1% of all locations published in the literature, with a total of 26 cases reported, only 5 regarding the pediatric population until 2020. Overall annual hemorrhage rate is 2.4%. Symptoms are often due to hydrocephalus and intracranial hypertension.Case Description: We report a case of a 5-year-old child with visual disturbances, headache, and progressive neurologic deterioration. MR showed a lesion in the pineal region and triventricular hydrocephalus. She was submitted to endoscopic third ventriculostomy and total excision of the lesion by the infratentorial supracerebellar approach a few days later. Histopathological examination confirmed a pineal cavernous malformation. The patient returned to her normal life without any neurologic deficit and a normal development.Conclusion: The ideal treatment is primary lesion removal; however, due to the infrequency and because it is a curable lesion, studies seeking to deepen the knowledge of this disease are considered relevant.

Letter to the Editor Regarding “Diagnosis of Ventriculoperitoneal Shunt Malfunction: A Practical Algorithm”

Arachnoid cysts are benign cerebrospinal fluid collection within a duplication of arachnoid membrane and, when found in the retrocerebellar site, they may be associated with tonsils herniation. This rare situation of coexisting retrocerebellar arachnoid cyst (AC) and Chiari malformation type 1 (CM-1) have been previously reported in few cases (10 patients) with syringomyelia and hydrocephalus described to be the most relevant issues. The aim of this paper is to describe 3 pediatric cases of this condition with a systematic review of the literature, underlining the importance of surgical management tailored to the pathogenic mechanism.A restrospective analysis of patients treated for coexisting CM-1 and ACs at the authors' institution has been carried out.A case of a 10-month-old baby with coexisting AC and CM-1 with tri-ventricular hydrocephalus treated with endoscopic third ventriculostomy, a case of a 1-year-old child with a huge retrocerebellar AC and CM-1 treated with a cysto-peritoneal shunt, and a case of a 15-year-old child with retrocerebellar AC causing symptomatic CM-1 treated with C0-C2 decompression, AC fenestration and duraplasty are described. A long-term follow-up is reported.Surgical management of coexisting ACs and CM-1 should not aim at the complete resolution of the cyst or of tonsil herniation, especially when pediatric patients are treated. Rather, the purpose of the neurosurgeon should be to understand the underlying pathogenic mechanism, and then restoring both the cerebrospinal fluid flow in the posterior fossa and the dynamic equilibrium between ventricles, cyst, and subarachnoid space.

Cranial and ventricular size following shunting or endoscopic third ventriculostomy (ETV) in infants with aqueductal stenosis: further insights from the International Infant Hydrocephalus Study (IIHS).

The craniometrics of head circumference (HC) and ventricular size are part of the clinical assessment of infants with hydrocephalus and are often utilized in conjunction with other clinical and radiological parameters to determine the success of treatment. We aimed to assess the effect of endoscopic third ventriculostomy (ETV) and shunting on craniometric measurements during the follow-up of a cohort of infants with symptomatic triventricular hydrocephalus secondary to aqueductal stenosis. We performed a post hoc analysis of data from the International Infant Hydrocephalus Study (IIHS)-a prospective, multicenter study of infants (< 24months old) with hydrocephalus from aqueductal stenosis who were treated with either an ETV or shunt. During various stages of a 5-year follow-up period, the following craniometrics were measured: HC, HC centile, HC z-score, and frontal-occipital horn ratio (FOR). Data were compared in an analysis of covariance, adjusting for baseline variables including age at surgery and sex. Of 158 enrolled patients, 115 underwent an ETV, while 43 received a shunt. Both procedures led to improvements in the mean HC centile position and z-score, a trend which continued until the 5-year assessment point. A similar trend was noted for FOR which was measured at 12months and 3years following initial treatment. Although the values were consistently higher for ETV compared with shunt, the differences in HC value, centile, and z-score were not significant. ETV was associated with a significantly higher FOR compared with shunting at 12months (0.52 vs 0.44; p = 0.002) and 3years (0.46 vs 0.38; p = 0.03) of follow-up. ETV and shunting led to improvements in HC centile, z-score, and FOR measurements during long-term follow-up of infants with hydrocephalus secondary to aqueductal stenosis. Head size did not significantly differ between the treatment groups during follow-up, however ventricle size was greater in those undergoing ETV when measured at 1 and 3years following treatment.

Outcome of Endoscopic Third Ventriculostomy: An Experience of 80 Treated Patients

Objective: To examine the outcome of Endoscopic Third Ventriculostomy in 80 consecutive patients operated in Irfan General Hospital and Prime Teaching Hospital Peshawar.Materials and Methods: Prospective observational study was conducted in the neurosurgery department of Prime Teaching Hospital and Irfan General Hospital Peshawar. 80 patients (48 male and 32 female) were followed for 3 months. The inclusion criteria all patients with Third ventricular hydrocephalus were included in this study and the exclusion criteria unwilling patients and those who opted for VP shunting rather than ETV. Data was analyzed using SPSS version 22.Results: ETV was performed in 80 patients. With highest success rate inAqueductal stenosis and posterior fossa tumors 88% and 87% respectively. ETV had a lowest success score of 50% in patients with Hydrocephalus TBM. Common post-operative complications were seizures and CSF leakage.Conclusion: ETV is less invasive and effective treatment for non-communicating hydrocephalus.ETV is most effective in treating aqueductal stenosis and posterior fossa tumors. The overall success rate of ETV is 74%. Based on these findings, it is recommended that ETV should be attempted as first line treatment for patients with triventricular hydrocephalus due to various pathologies.

EP16.30: Fetal triventricular hydrocephalus associated with different findings in pre‐ and postmortem fetal magnetic resonance imaging: a case report

We present a case of fetal triventricular hydrocephalus associated with distinct different findings in the fetal cerebellum and liver when comparing pre- and postmortem fetal magnetic resonance imaging (MRI). A 34-year-old, gravid 2, para 1, woman underwent prenatal ultrasound examination at 22+4 weeks of gestation which showed a triventrucular hydrocephalus, along with hepatic calcification, a hyperechogenic intestine, ascites, mild pericardial effusion, and a white spot in the left ventricle without hemodynamic significance. The ultrasound examination at 13 weeks gestation had been completely normal. TORCH infection screen was negative. The couple declined invasive diagnostic screening for genetic analysis. The prenatal fetal MRI that showed suspicion of cerebellar infarction as the cause of the triventricular hydrocepalus. The liver calcification, with a hyperechogenic intestine, ascites, moderate pericardial effusion, and white spots in the left ventricle were confirmed. After intensive interdisciplinary counselling, the couple opted termination of pregnancy. After delivery the fetus underwent post-mortem fetal MRI, 6 days following the initial scan. This MRI suggested a cerebellar vascular malformation with minimal bleeding and subarachnoid hemorrhage but also showed a novel finding: hemangiomatosis of the liver with minimal bleeding and under perfused liver parenchyma. In conclusion, the use of post-mortem fetal MRI may be useful to identify pathological findings not evident in pre-mortem MRI due in part to the greater precision of the examination. Postmortem examination of the brain is often inconclusive. The use of post mortem MRI instead of autopsy offers a non-invasive way to identify the cause of fetal malformations. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

A multimodal staged approach for the resection of a Sylvian aqueduct rosette-forming glioneuronal tumor: A case report and literature review

Abstract Background and importance The rosette-forming glioneuronal tumor (RGNT) is a rare central nervous system tumor which often arises intraventricularly. We report the first surgical case of an RGNT arising from the Sylvian aqueduct treated through a double approach. Clinical presentation A 25-year-old female presented with triventricular hydrocephalus on MRI secondary to a 2 cm Sylvian aqueduct mass. Emergent endoscopic third ventriculostomy with biopsy confirmed the diagnosis of RGNT. She was first followed up and due to the rapid tumor's growth a double surgical approach was proposed. The first was a telo-velar approach to the lower third of the aqueduct. The second stage was an endoscopic ultrasound aspirator aided transfrontal transforaminal approach; last postoperative MRI shows a 6 mm residual tumor. Patient leads an active working and social life. Conclusion Choosing a two stages approach for this rare and complex Sylvian aqueduct RGNT resulted in a positive clinical and radiological outcome.

Acute cerebellitis in paediatric patients: Our experience

IntroductionAcute cerebellitis is a rare inflammatory disease with a highly variable clinical course that ranges from benign self-limiting symptoms to a fulminant presentation associated with a high risk of death due to compression of the posterior fossa, acute hydrocephalus, and intracranial hypertension. MethodsWe reviewed clinical, laboratory, and radiological findings from children diagnosed with acute cerebellitis between May 2007 and November 2016. We analysed treatments and clinical and radiological progression. ResultsNine children met the diagnostic criteria for cerebellitis. Headache, vomiting, and drowsiness were the most frequent initial symptoms; ataxia, dysarthria, and dysmetria were the most common cerebellar signs. Cerebellitis was diagnosed with magnetic resonance imaging, which revealed cerebellar involvement (unilateral or bilateral); computerised tomography images either were normal or showed indirect signs such as triventricular hydrocephalus due to extrinsic compression of the aqueduct of Sylvius. Corticosteroids were the most commonly used treatment (6 patients). One patient required surgery due to triventricular hydrocephalus. Eight patients recovered completely, whereas the ninth displayed neurological sequelae. ConclusionsCerebellitis is a medical and surgical emergency; diagnosis requires a high level of suspicion and an emergency brain magnetic resonance imaging study. It is a clinical-radiological syndrome characterised by acute or subacute encephalopathy with intracranial hypertension and cerebellar syndrome associated with T2-weighted and FLAIR hyperintensities in the cerebellar cortex (unilaterally or bilaterally) and possible triventricular dilatation. Treatment is based on high-dose corticosteroids and may require external ventricular drain placement and decompressive surgery.

Combined endoscopic third ventriculostomy and tumor biopsy in the management of pineal region tumors, safety considerations

BackgroundPineal region tumor is considered an ideal indication for endoscopic third ventriculostomy (ETV), with success rate up to 92%. The ultimate advantage is the ability to obtain tumor biopsy for histopathological diagnosis and for further treatment strategy plan design.ObjectivesTo investigate the safety considerations to minimize tumor biopsy-related bleeding, increase diagnostic accuracy, and establish a successful ETV procedure.MethodsRetrospective study including 25 patients of pineal region tumor with concomitant triventricular hydrocephalus. Preoperative planning to perform ETV and obtain tumor biopsy was achieved either through single more anteriorly located precoronal burr-hole (17 patients) or two separate burr-holes (eight patients). The patients’ age ranged from 9 months to 65 years with a mean age of 26.5 years. Preoperative MRI brain with coronal T2- and sagittal T1-weighted images was used to design trajectory.ResultsNo significant intraventricular bleeding reported. A diagnostic tumor biopsy yield was successful in 22 patients. Ventriculoperitoneal shunt insertion was required in 1 patient failed to improve.ConclusionEndoscopic tumor biopsy is relatively safe with high diagnostic yield that helps in management protocol plus shunt independent control of associated hydrocephalus.

International Infant Hydrocephalus Study (IIHS): 5-year health outcome results of a prospective, multicenter comparison of endoscopic third ventriculostomy (ETV) and shunt for infant hydrocephalus

One of the most important unanswered questions in pediatric hydrocephalus is determining whether treatment with endoscopic third ventriculostomy (ETV) versus shunt results in improved health status and quality of life (QOL). To answer this, the International Infant Hydrocephalus Study (IIHS) was started in 2005 as a prospective, multicenter study to compare ETV and shunt in infants (< 24months old) with symptomatic triventricular hydrocephalus from aqueductal stenosis. Herein, we present the 5-year primary outcome results. IIHS utilized a prospective comprehensive cohort design, in which patients received ETV or shunt, based on either randomization or parental preference. For this analysis, we pooled the randomized arm and the parental preference arm, analyzing them together. At 5years of age, children were assessed with the Health Utilities Index Mark 2 (HUI-2) (primary outcome) and the Hydrocephalus Outcome Questionnaire (HOQ), a measure of QOL. Results were compared in an analysis of covariance, adjusting for baseline variables including age at surgery and baseline development status. From a total of 158 patients who met eligibility criteria, complete 5-year outcomes were available on 78 (19 treated initially with shunt, 61 treated initially with ETV), assessed at a mean age of 62.1months (SD 6.3). The mean 5-year HUI-2 utility score was 0.90 (SD 0.19) for ETV and 0.94 (SD 0.10) for shunt (p = 0.21). The mean 5-year HOQ overall score was 0.81 (SD 0.15) for ETV and 0.85 (SD 0.12) for shunt (p = 0.42). Similarly, there were no significant differences noted between 5-year HOQ subscores (cognitive, social-emotional, physical) or developmental measures at 1, 2, and 3years. This is the first prospective direct comparison of long-term outcomes of ETV and shunt for infant hydrocephalus. These results suggest that overall health status and quality of life in this cohort of infants treated for aqueductal stenosis are high, with no significant difference between those treated initially with ETV or shunt. NCT00652470.

Asymmetric hearing loss and chronic dizziness in a patient with idiopathic normal pressure hydrocephalus.

We report a case of a 54-year old female patient, complaining for chronic dizziness, hearing loss, tension headaches without aura, postural instability and gait dysfunction. The patient referred having these symptoms from 1992, but the last few months she experienced a noticeable aggravation of the symptoms. A magnetic resonance imaging test revealed a triventricular hydrocephalus, not associated with signs of intracranial hypertension decompensation. The ENT-Audiology evaluation revealed a bilateral sensorineural hearing loss with a conductive component, video-nystagmography resulted in an areflexia of the right ear and a reduced vestibular activity for the left ear. Auditory brainstem response test was also carried out and showed pathologic findings for the latencies of the waves I-III, III-V and I-V bilaterally but more significant in the right ear. On January 2016 the patient had endoscopic third ventriculostomy. On the follow up the patient referred an important subjective improvement regarding instability and gait dysfunction. In this paper we study the correlation between hydrocephalus, hearing loss and vestibular dysfunction.

Subclinical meningoventriculitis as a cause of obstructive hydrocephalus

Communicating hydrocephalus may complicate infantile bacterial meningitis, typically presenting with systemic features of infection. We report a rare case of ‘subclinical meningoventriculitis’ causing obstructive hydrocephalus and its challenging management. A...

Imagerie Des Retars Psychomoteurs De L’enfant A Lome

Objective: To determine by radiology the different etiologies of psychomotor delays (PMD) in Lomé (Togo). Material and Method: Retrospective study of 12 months in the radiology department of CAMPUS Teaching Hospital, concerned images of CT and MRI scans of children 0-16 years of age with PMD. Results: The mean age was 4.4 years +/- 4.35. The result was pathological in 69.63% of the cases.Cerebral atrophy was the most frequent lesion (40.50%), followed by hydrocephalus (23.14%). The congenital stenosis of the Sylvius aqueduct was the most frequent malformation (37.93%). Triventricular hydrocephalus accounted for 45.61% of hydrocephalus. The most common tumor lesions were choroid plexus carcinoma and craniopharyngioma (28.57% each). Meningo-encephalitis accounted for half of infectious cases. Conclusion: PMD is most often the consequence of several cerebral pathologies. The most frequent of which is cerebral atrophy.

Hydrocephalus and psychiatric disorders: About a clinical case

IntroductionHydrocephalus is a neurological disease caused by excessive accumulation of cerebrospinal fluid following an abnormal secretion, circulation and absorption. It is considered the most common reversible cause of dementia but still an underestimated cause of psychiatric disorders.ObjectivesHighlighting the possible association of hydrocephalus in some psychiatric disorders and know how to adapt the management of this co-morbidity.Clinical VignetteHe is Mr O.Y, aged 27, unmarried, his parents divorced, lives with his mother. He had surgery in 2012 to the orthopedic service for disabling scoliosis. No significant psychiatric family history. Discovery of a tri ventricular hydrocephalus in 2011 requiring regular monitoring neurology.Indeed Mr O.Y followed the CMP for a mood disorder requiring antidepressant treatment based. The evolution of disorder was marked by the installation of a hallucinatory and delusional syndrome motivating several hospitalizations and relapses iterative partial response to various therapies.Mr O.Y was received a ventricular shunt within the sound hydrocephalus.The postoperative course was marked a progressive amendment acoustic verbal hallucinations and delusions of persecution.The conduct was to gradually reduce the dose of antipsychotic (Risperdal) to the stop. No recurrence pathological productions.ConclusionsPsychiatric disorders may mark the evolution of hydrocephalus. Share against the indications and side effects of some psychotropic drugs, the management of this co-morbidity may be difficult. Further studies are needed to better elucidate causality for this association and to develop appropriate therapeutic consensus.Disclosure of interestThe author has not supplied his/her declaration of competing interest.

Cerebelitis aguda en Pediatría: nuestra experiencia

IntroductionAcute cerebellitis is a rare inflammatory disease with a highly variable clinical course that ranges from benign self-limiting symptoms to a fulminant presentation associated with a high risk of death due to compression of the posterior fossa, acute hydrocephalus, and intracranial hypertension. MethodsWe reviewed clinical, laboratory, and radiological findings from children diagnosed with acute cerebellitis between May 2007 and November 2016. We analysed treatments and clinical and radiological progression. ResultsNine children met the diagnostic criteria for cerebellitis. Headache, vomiting, and drowsiness were the most frequent initial symptoms; ataxia, dysarthria, and dysmetria were the most common cerebellar signs. Cerebellitis was diagnosed with magnetic resonance imaging, which revealed cerebellar involvement (unilateral or bilateral); computerised tomography images either were normal or showed indirect signs such as triventricular hydrocephalus due to extrinsic compression of the aqueduct of Sylvius. Corticosteroids were the most commonly used treatment (6 patients). One patient required surgery due to triventricular hydrocephalus. Eight patients recovered completely, whereas the ninth displayed neurological sequelae. ConclusionsCerebellitis is a medical and surgical emergency; diagnosis requires a high level of suspicion and an emergency brain magnetic resonance imaging study. It is a clinical-radiological syndrome characterised by acute or subacute encephalopathy with intracranial hypertension and cerebellar syndrome associated with T2-weighted and FLAIR hyperintensities in the cerebellar cortex (unilaterally or bilaterally) and possible triventricular dilatation. Treatment is based on high-dose corticosteroids and may require external ventricular drain placement and decompressive surgery.

Hydrocephalus and Danty Walker Cyst, a Study of 33 Cases in Friendship Hospital Sino-Guinea of Kipe in Guinea

Malformations (or cysts) are developmental malformations in which the Cerebellar Vermis may be partially or completely absent, with resulting dilation of the 4th Ventricle forming a Cyst. It is thought that the defect arises from abnormal embryogenesis of the roof of the 4th Ventricle. A milder form is termed the Dandy-Walker Variant. This disorder may account for approximately 5% to 10% of cases of Ventriculomegaly. This study aims to reveal particular cases of Danty Walker Cases when associated with hydrocephalus, in the African context. It is a retrospective and descriptive study carried out at the Neurosurgery department of the Friendship hospital of Kipe in Guinea for 36 months, from June 2012 to August 2015. Of the 120 patients hospitalized for hydrocephalus, 32 cases have exhibited the Dandy Walker cyst. Among the 32 patients, 15 were of male and 17 were of female gender at a sex ratio (H/F) of 0.88; 1. The dominant clinical symptoms that were observed in our subjects were macrocrania (32 cases), bulging fontanelle (25 cases), sunsetting eyes (19 cases). The degree of macrocrania was noted to be minimal in 1 case only, mild in 5 cases, moderate in 8 cases, and excessive in 18 cases. Furthermore, CT scan results showed evidence of triventricular hydrocephalus in 14 cases, and tetraventricular hydrocephalus in 18 cases. The anatomical variations encountered among others were, MDW in 15 cases, DWV in 11 cases et DWC in 6 cases. The calculated Evan’s index was equal to 0.3 in 6 patients and greater than 0.3 in 26 patients. The operative techniques most commonly widely conducted were DVP (16 caes), VCS (13 cases) and DKP (3 cases). The average duration of hospitalization was 20 days with extreme range of 1 to 49 days. The post operative period was uneventful in 16 cases, clinically unchanged in 5 cases and post operative deaths were reported in 11 cases. The principal causes of death originated from the presence co-existing infections, respiratory distress, anemia and malarial sickness.

Secondary vein of Galen malformation with hydrocephalus: Treated with combined endovascular and endoscopic approach

Our goal is to describe a case of hydrocephalus in the setting of a Yasargil Type IV-C secondary vein of Galen malformation (VGM), treated with a combined endscopic and endovascular approach. We retrospectively reviewed the records of a patient admitted to the neurosurgical department hydrocephalus related to a secondary VGM. A 47 year old male, presents with 8 months of progressive headaches and gait ataxia. Imaging displays a triventricular hydrocephalus, a tectal AVM, and an aneurysmal dilation of the great vein of Galen. Angiography displays a tectal AVM supplied by bilateral posterior choroidals with drainage into the vein of Galen. In addition there were direct high-flow arteriovenous fistulas into the vein of Galen via meningeal feeders. The diagnosis of a Yasargil Type IV-C secondary VGM was made. The patient was treated via a combined endoscopic and endovascular approach. An endoscopic third ventriculostomy (ETV) was conducted for his hydrocephalus. He subsequently underwent a partial endovascular embolization of the left tentorial arterial feeder 1.5 months after his ETV. Post-operatively his hydrocephalus resolved, and his complex secondary VGM completely obliterated after a single partial embolization. Secondary VGMs with associated high-flow arteriovenous fistulas are rare. Our case provides a nice example a combined endoscopic and endovascular approach aimed at achieving cure of the hydrocephalus and the Yasargil Type IV-C secondary VGM. We were able to avoid the placement of shunt hardware via ETV treatment of the patient's hydrocephalus. Furthermore, our case displays the impact of partial embolization on control and potential cure of these complex vascular malformations.